Crisis Management Leadership

Tuesday, August 15, 2017

Resiliency: "Failure is not a destination!" Words of
advice by Coach Mike Krzyzewski at the annual Feagin leadership program - Duke
University.

The 2016 annual Feagin leadership
program focus was on Resilience. Coach K reminded us that "Failure is not
a destination"! You must learn to survive a failure. These are my thoughts
and reflections based on Coach K's talk which truly resonate with all surgeons.

"Why is it that professionals find
it so difficult to move past a failure?" He asked. Coach K stated that
"The problem with being a 'winner' is that we are always prepared to win
and when we fail", we find it difficult to move past that point, recover
and move on. But it does not have to be that way. We were reminded that we are leaders
because over time we have learned to be resilient. It is in our nature. We need
to train ourselves to remember that at our darkest hour, we need to pull
through, move forwards (refer to Admiral McRavens commencement address at UT in
a prior post of mine), gain knowledge from that failure and find a way to
improve for the next time.When failure
occurs, you need to look to the future. It may sound simple now, but this can
prove difficult for those who are accustomed to constant success. "We are
winners. We are accustomed to winning." We need to think of these
experiences as stops on the train route- at some point the train has to stop
either as a planned or unplanned event. But it must carry on after each stop
and move on.

Unfortunately when we encounter
failure, we tend to focus inwards and become silent when, (as Tom Kolditz
teaches us) we need to be outwardly focused. To be resilient, you cannot
survive alone. "A really good leader doesn't go it alone". To move
forwards you need to work as a team. This does not begin at the moment you
encounter failure but far ahead of that failure. Teamwork comes from training
together to make improvements. Through this your team develops trust. When your
team trusts you, you can survive anything.

To be a good leader in
basketball, you need to be willing to run a "motion" offense. In a
motion offense, you are less structured but adapt to the defense. A resilient
leader in any profession recognizes when the situation is declining and adjusts
his offense to suit. They make changes based on their read of the situation
before things collapse. You make "reads" based on your opponent and
your team. You don't wait till everything "goes into the pot. A good
leader rescues his team or allows his team to rescue themselves".
"The best teams have leaders on the court who can make those
decisions".

Coach K, explained that to become resilient you need four
characteristics: an adaptive attitude, the belief you will overcome adversity,
the acceptance that from that failure you can make changes, and the ability to
move forwards.

1.Attitude-
we need a great attitude. After the failure and you have taken a moment to
release your exasperation and frustration you need to be sure everyone has a
great attitude. Without that positive attitude you will not recover.

2.Belief-before you encounter failure you need to
establish belief amongst your team. belief in what you and your group can do.
"Belief does not go out the window when things go bad. Belief has to be
heightened when things go bad".

3.Make
changes- after a failure something has to change. You can't go back to the same
way of doing things and then wonder why you failed again.

4.Go forward- finally, after you have
encountered a failure, you need a plan to move forwards. You can use the
failure as a lesson but you cannot allow it to stop your train. The train needs
to keep moving forwards.

Saturday, December 3, 2016

At
the 2016 ACS Clinical Congress, the Committee on Trauma sponsored a panel
discussion: “The Committee on Trauma Perspective on Firearm Injury and
Prevention”. During the panel, Joseph A. Ibrahim*, MD FACS discussed “Incorporating
Lessons Learned - Pulse Club Massacre”. Immediately following the
presentation, I approached Dr. Ibrahim to see if he would speak to me regarding
his impression of the overall response to the situation and his personal
response.

Orlando
Florida, Sunday, June 12, 2016:

At 2;15 am Joseph A
Ibrahim was at home (having been on call the Friday before and schedule to be
back on call that Sunday) when he received the call from his partner and
Orlando Regional Medical Center (ORMC) trauma attending on call Chadwick P.
Smith MD, FACS that there was a gunman downtown with approximately twenty
victims and they needed him to return to the hospital. As he entered the trauma
bay he knew immediately that this was “larger than our usual Friday/Saturday
night penetrating trauma but the vastness of it all had not hit”

At 1:57am a gunman entered the Pulse
nightclub carrying a Sig Sauer military assault rifle and a Glock pistol,
opened fire and within five minutes caused the deadliest mass shooting in US
history. By the time Police arrived at 2:07, he had fired 250 rounds into the
crowd ultimately killing 49 and wounding 58 victims.

At 2:00 am ORMC was notified about a
mass shooting involving at least twenty victims, three blocks from the medical
center. Within 10 minutes, patients began arriving at a rate of one per minute
by private vehicles, police cruisers or carried in. Dr. Smith hurried to the
trauma bay, accompanied by the general surgery resident team, as the victims
began arrive.

ORMC is a very busy trauma center which
cares for over 5000 trauma cases a year. Typically, these are blunt trauma
cases or isolated penetrating trauma, but it is not uncommon for several
gunshot wounds to be treated in an evening. ORMC was not caught off guard. For
the past 20 years, the facility has participated in coordinated trauma training
drills with their local EMS teams. They participate annually in their community
mass casualty drills. In fact, just three months prior they were engaged with
the tri-county active shooter mass casualty drill (Dr. Ibrahim showed us their
comprehensive mass-casualty plan that has been refined as a result of these
drills). As the morning wore on, it was clear that that preparedness paid off.

Of the Thirty-eight patients who
arrived within the first 42 minutes only nine died. All told 49 victims and one
SWAT member arrived at the trauma center that morning. Typically, the facility
has a single operating room staffed and ready during the evening. However, on
this night, an hour after the patients began to pour in, four operating rooms
were functional and an hour later two more were in operation. Twenty-nine
operations were performed in the first 24 hours and a total of 54 total by the
end of the week (78 total operations resulted from this disaster). All told,
441 units of blood were transfused into the Pulse nightclub victims. [for
details see: http://bulletin.facs.org/2016/11/orlando-regional-medical-center-responds-to-pulse-nightclub-shooting/ ].

Dr.
Ibrahim explained a few keys to success of the team:

1.You teams must engage in Rapid PROPER triage and assessment
of victims.

2.Your team leaders must call in reinforcements within 10-20
minutes! You cannot hesitate or you will likely lose your window of
opportunity.

3.You must maintain flexibility and assume the worst while
continuing to work.

a.Due to the uncertainty of the existence of a shooter in the
facility, the facility went into “Code Silver” lockdown alert but continued to
appropriately care for their patients.

b.They normally had a single OR after hours but had to quickly
staff, equip and supply 5 extra rooms within two hours.

c.The Hospital System focused on centralizing the hospital
staff where the patients arrived likely avoiding failure to rescue. Initially
they considered diverting the patients to other hospitals in the system but the
administration quickly saw the sense in sending outlying hospital staff to the
Level 1 Trauma center and keep the patients there instead. The majority of the
trauma occurred within an extremely short time period as the shooting was
rapidly over and the origin just a few blocks away. Having a backup system
already in existence meant that the slower response from outside personnel was
not a factor and this clearly contributed to the survival rate (only 9 patients
died at the trauma center).

4.Accurate charting and patient tracking is a must! If it is
rehearsed and run appropriately it should not interfere with patient care and
in spite of the massive volume of injuries a system should be established for
charting and tracking every patient. Maintaining a master list of victims
tracking each patient’s injuries, laboratory data, and radiologic studies
allowing follow-up evaluations to assure no patient had missed injuries.

5.Precise communication response is key especially between the
surgeons and anesthesia providers.

He
also explained a couple of unforeseen shortfalls of their system that were
recognized as the scene unfolded:

1.Insufficient Family Assistance Program: The large influx of
victims accompanied by overwhelming response by family members and friends
seemed effective initially as the facility responded with a family assistance
center, providing regular updates. The system provided constant communication with
families which resulted in identification of virtually every victim in the
first twelve hours. Unfortunately, the sheer volume of food, water, clothing,
support staff etc was not anticipated as the families poured in.

2.Unrecognized victims-Counselling needs: The facility disaster
plan did not anticipate the post-event counseling needs of patients, families,
EMS, Police, hospital staff or the community as a whole in the aftermath of an
event of this magnitude. The psychological burden placed on those involved was
overwhelming. 1500 hospital staff participated in counseling over the first TEN
days. No one was immune. Remember to assign partners to continually assess for
late signs of PTSD.

Dr.
Ibrahim agreed to talk with me regarding some questions I had following his
talk:

LEADERSHIP ANALYSIS:

In
your talk, you described several leadership characters that are important
during a crisis:

·Experience in difficult situations,

·Great interpersonal skills,

·Strong when needed but lets others work,

·Flexible/innovative

·Decisive.

-Can
you expand on these? Can you give examples of where you saw this in action?

-What
aspect of your leadership training appeared to help the most?

-Anything
in yourself or others surprise you? That is you did not expect you or another
to perform as well in that aspect?

-Any
leadership character you previously thought you would have excelled at, but
believe you fell short?

1. Experience in difficult situations:As I alluded to true mass triage is something
most of us do not have experience with outside of the military.Determining when enough has been done usually
occurs long after we’ve contributed significant time and resources to salvage
someone we likely believe will not have return of vitals.In these situations, you have to have the
individual that can recognize when you need to halt potentially futile efforts
for the good of the other victims.Our
physician in charge did an excellent job of that on this occasion.We still performed “heroic measures” on
multiple occasions but he was incredible at recognizing when we needed to halt
efforts and move on to someone who had a chance.

2. Great interpersonal skills:This can be summed up by “Great team play”.Again, we practice with our mock traumas on a
regular basis and that fact that we have 4800 traumas a year gives us even more
opportunity to work together.This gives
us the opportunity to know each other by name and ask for things specifically
in the trauma bay rather than just yelling out into the air “I need a chest
tube”.As my team hears me say often,
when you yell to someone to fetch something, someone becomes no one and that
delays care.So by knowing each other by
name and asking someone specific for an item, it improves time, efficiency, and
overall care.

3. Strong when needed but let others work.One of the most difficult skills for us
“control freaks”.Being able to let
others do as trained and not micromanage.There is no time for this anyway. However, the leader(s) must remain
objective.In this particular situation,
we needed someone to tell us or others when to stop resuscitations so that we
could go on to the next more likely salvageable patient.Other examples include lifting others
up.Example: I remember calling the OR
to say we were coming and the person on the other end asking for time to open
the room.We had to tell them we are
coming and you can open the room around us to which they quickly complied.This also demonstrated flexibility.We were also flexible in dealing with the
possible shooter in the ED by keeping surgeons in the OR and sending patients
up rather than each surgeon coming down, evaluating the patient and taking them
up individually.You have to have trust
in your team.

4.Our group excelled at flexibility, prompt action, teamwork and
coordination.We have gone over and over
the response and honestly cannot find a weak point.This went better than any drill we’ve
performed.I think we could have thought
sooner about going to the paper h&ps and filling those out to have a more
complete evaluation on the chart as opposed to what typically happened which
was face to face hand off which is something we do with our ICU patients going
to the OR every day between ICU and anesthesia.

The extent really didn’t hit until all the initial surgeries were
done.I stayed focused on the job at
hand by gathering the troops (residents and extenders) and dividing up tasks:

1)tertiary exams on all the pulse victims
to assess for more minor injuries that may have been missed.

2)divided the extenders with
residents to round on the patients on the services not involved with the mci

3)discussed with partners rounding
plans

4) saw two new consults (appy and
incarcerated hernia)

TEAM RESPONSE AND PREEMPTIVE PLANNING ANALYSIS:

-How
was the team response? That is, was communication crisp and clear assuring as
succinct a response as possible?

-The
time worn adage is “no battle plan survives the first encounter with the enemy”
so how extensive / realistic did your team drills appear in retrospect? How
well were you prepared? Did you have to scrap anything immediately?

-What
aspects do you all now realize need enhancement?

-Your
personal lessons learned?

-Facility
lessons learned?

-Did
the residents step up to the plate?

-When
was the decision made to have the trauma surgeons stay in the OR in lieu of
going back to the ED to assist? What forced that decision?

Team response was
amazing.The communication was
outstanding but as you allude to this is something we drill as well.The teams hear me say often “someone becomes
no one” .This means that yelling things
out into the air when you need something often goes unheard.“I need a chest tube!” yelled into the air
often goes with no one hearing it.However, eye contact, direct names, all things we drill much like the
WHO checklist in the OR.I have tried to
implement this into the trauma setting but it is a work in progress.That being said, the deliberate communication
practiced in the mock alerts did help significantly.Our community wide drills are extremely
realistic with moulage and transport of patients to the planned areas (OR, icu,
floor).If you would have asked me prior
I would have not known how prepared we were.I knew all we had in place and the drills we do but we never live up to
our own expectations in the drill.We
far surpassed how I thought we’d respond when the event occurred.Not much was scrapped, instead we did add: surgeons
stay in OR, OR open around patient, we have 26 OR’s so instead of cleaning a
room and waiting, just open another room and have someone else clean the room
just used so that if needed, we use all 26 rooms.We do want to continue to enhance our drills
and we have.We use our sim man
regularly and seem to have more involvement with ems.We want to expand to have PD
involvement.The biggest learning point
was delaying with family and how to obtain identification.Several of our administrators have since
developed a program for people to send in pics and or descriptions of loved
ones on a list to the facility to allow for quicker identification.The other learning point with family is
having certain necessities, the biggest issue was phone chargers which our
patient experience administrator quickly went out and bought a multitude of to
provide for families.You also need
medical staff with the families as some experience medical issues during this
time of great stress.

With regards to the
residents, they stepped up in a huge way.We could not have had these results without them and the fellows.Some were upset that they were either gone or
slept through the mci page and came in late but it was a blessing that we
didn’t anticipate.You need enough
personnel with the initial surge but you need people to then round and give
those there initially a break if possible so the delayed response of some was a
gift from God and moving forward, a progressive response would be favored over
an all-out surge at the onset.I think
I answered this above but the decision to keep the surgeons in the OR occurred
with there was concern for a gunman in the ER at which point, the second wave
of surgeons had been called in but could not get into the ED.Again, another blessing as this worked way
better than we could have ever anticipated.

Sincerely, Joseph Ibrahim

I
have some follow-up questions for Dr. Ibrahim regarding personal resiliency:

Any
lessons on personal resiliency from this? Ie how are you doing? Did you find
that specific lifestyle routines or changes allowed you to “survive” this
event?

Monday, November 28, 2016

TEAM
ORGANIZATION IN TRAUMA IN AN AUSTERE ENVIRONMENT: TRAUMA AND EMERGENCY SURGERY
IN UNUSUAL SITUATION. An Interview with Seon
Jones LCDR MC USNR

Earlier in 2016, COL Robert B. Lim,
MD, U.S. Army, edited a landmark text Surgery during natural disasters,
combat, terrorist attacks, and crisis situation. I had the opportunity
to chat with Dr. Lim about his text. Having been deployed numerous times into
the zone of combat, I believe he can be considered an expert in this area.
Several chapters peaked my interest (especially the one on unexplored
ordinances), but the chapter written by Seon Jones and Gordon Wisbach on "Trauma
in an Austere Environment: Trauma and Emergency Surgery in Unusual situation"
interested me most due to the details provided on trauma teamwork in the combat
environment. Trauma teamwork is difficult enough under normal circumstances,
but just imagine managing a team in remote or hostile environments.

In their chapter Jones and Wisbach
reinforce the need for strict organization and planning. There is no room for
error. They reiterate that success starts with Mass Casualty Planning and
Rehearsal. After arrival to the operational area the team should discuss and
rehearse the casualty plan. Preparation includes memorizing the layout of the
trauma area, the facility as well as the outlying areas. Defined team positions
and roles are key to avoid confusion and delays. In spite of the appearance of
redundancy, prior to each incoming casualty, stating names and roles avoids
confusion. Continued repetition focuses the team and reminds the team about
potentially forgotten measures (PPE, civil closed loop communication). Team
member names should be readily visible on each member to assure communication
is clear and avoid distractions. Supplies and equipment need to be in
standardized placement close to the immediate resuscitation area to avoid
excess noise in asking or searching for supplies.Each team member has an assigned checklist
posted at their work station (detailed summary of those checklists noted in
their chapter). The trauma team leader (TTL) should stand in a routine position
where they have continued observation of the team (i.e. Foot of bed). One
examiner is then on one side of the patient and the other examiner or RN on the
other. Anesthesia should be at the head of the bed. Prior to patient arrival,
each member needs to confirm their checklist has been reviewed. Team review
should remind the team that only the TTL should be providing resuscitation
instructions thereby avoiding the confusion that results from too many members
instructing the team. A hierarchal structure helps to maintain the TTL's
situational awareness. The TTL needs to remember to take a pause for
summarization prior to and after critical steps in the resuscitation process-
preintubation, post-BP stabilization- to avoid missing crucial details. The
authors remind us that in spite of combat casualties occurring in austere
environments, following standard clinical practice guidelines (CPG's) is vital-
just because you may be remote, standard evidence-based protocols avoid
conflict and improve team dynamics. Several other reminders of TTL roles are
highlighted in this chapter.

Finally the authors remind us of
three vital team leadership roles- 1. watch for and control team stress and
conflict 2. Be cognizant of Bruce Tuckman's revised stages of group development
(forming, storming, norming, performing, and adjourning) to assure your team is
developing appropriately 3. Morale retention and support from "compassion
fatigue" is necessary to survive the arduous often primitive
conditions.

I
immediately had a few questions for the authors and when I met up with Gordon
Wisbach at the Excelsior meeting in advance of the ACS Clinical congress he
agreed to discuss these.

1. I constantly
hear from surgeons that checklists and teamwork principles have no place
in emergency or life-threatening situations. When we discuss following
the WHO and checklist principles, frequently heard complaints are:
"the patient is dying! following these recommendations simply wastes
valuable time and is not necessary". I hear the complete
opposite in your assessment of how to manage a team in life-threatening
poorly supplied environments. Have you had success in
promoting these principles in civilian arenas? If yes, how do you convince
others that moving fast without direction and rehearsal may slow you down?

Part
of the reason for the usual resistance against check lists: Long, detailed,
rigid, generic, all-inclusive checklist are arduous to follow and meaningless
in some locations. Checklist for emergency/life-threatening
situations/crises should be developed differently than those designed to be
implemented in a controlled, mindful setting. A good analogy is a
checklist prior to take off of a plane where you should take your time and
focus on not missing key safety measures versus checklist that pilots and crew
take during in-flight emergencies where seconds matter. Even in the
second scenario, they run through a checklist efficiently and effectively
without error even though most medical personnel would think that it would slow
the pilot down and the plane would crash before he even opens up the checklist.

The
reason the emergency checklist works is because they practice and drill the
list so that ALL of the important steps are taken in a specific sequence
without fail. This is the principle we are very resistant to apply for
major trauma resuscitations. What we don't realize is that, as medical
professionals, we already subscribe to the checklist principle whenever we take
ACLS and BLS courses or do ACLS drills. We practice those drills with the
algorithms printed out on cards as cognitive aids, but we know the important
first steps of that checklist by heart: 1. Open the airway, 2. Give breaths, 3.
If no pulse, start compressions, 4. When the AED or crash cart arrives, check
rhythm, 5. Shock or give drugs, etc.

The
emergency checklists should be designed considering the frame of mind of
someone who is in the emergency situation, traumatic injuries in our
case. After developing the list, it should be drilled and tested.
The actual emergency situation should not be the first time a team or an
individual goes through the checklist. It should be deliberately
practiced and drilled. Also, in this process, you may discover that some
steps in your checklist are not appropriate (not practical, not useful,
counterproductive, etc.)

In
regard to, in your words, convincing others that moving fast without direction
and rehearsal may actually be counterproductive, those others should try to
remember those times when they just jumped into doing a procedure without all
the necessary equipment, supplies, and set up. They may have been all
gowned up and gloved, but the patient was not prepped, yet, the chest tube was
not in the room, there were no drapes, no scalpel, no hemostats, no drugs for
sedation and the patient is moving too much, etc. The patient received
paralytics, but you didn't get the laryngoscope, didn't check the light was or
was not working, now you're bagging him, but the O2 tank is empty, who checked
the O2 tank? Ok, now the laryngoscope is here, but you can't see cords, oops we
didn't plan for a difficult airway, no fiberoptics, no bougie, no LMA, need a
surgical airway, stat? where is the scalpel, where is the crich tube or the 4-0
endotracheal tube, etc.

2. When you
first went into action, what preconceived notions were instantly proven
false?

The preconceived notion that only
the medical providers were essential personnel is false. In a resource
and personnel scarce environment, everyone is vital to running an ongoing
casualty receiving area. For optimal throughput, all the steps from
restocking supplies, preparing the room for a resuscitation, litter bearing,
and cleaning to be ready for the next casualty are important steps.
Nothing conveys the importance of these details than actually carrying out
these tasks yourself when you can. It's like pre-flighting your trauma
bay/ED/OR like a pilot pre-flights or looks over the aircraft he is about to
fly.

3. When you arrived
at a designation, was there anything that totally caught you by surprise?

In retrospect, it is incredibly rare
to see the type of multi-dimensional injuries of blast casualties in any
civilian setting. The only similar situations I can recall off the top of
my head are the Boston Marathon bombing, the Oklahoma bombing, and may be
9/11. It would be much simpler in comparison to have straight forward
gunshot wounds or blunt trauma from a fall or MVC. The war time
casualties come with the myriad of unique injuries characterized by blast
injuries.

4. Describe the most
remote, austere operating environment you faced? Any take homes from that
experience?

One
room OR with two OR tables in an old Soviet Era hardened structure. Take
home points: Forget about sterility expected in a US hospital OR, the
casualties have wounds that likely more contaminated than an un-sterilized
instrument in the OR. Of course, we still followed the surgical
principles and used sterile procedures and equipment. In these austere
settings, advanced, expensive, cumbersome medical technology is not as good as
your/your team's knowledge and training and you/your team are the patient's
best chance of survival. The other basic necessities are lights,
headlights (nothing fancy), electricity, sterilizer, basic general surgery,
thoracic, vascular, and orthopedic sets, IV fluids, blood, and transfer
facilities.

The
overall take home point I would say is to take the time to read the lessons learned
from the prior team if you are fortunate enough to have that resource.
There is no pride in delivering sub-optimal care while trying to reinvent the
wheel. Also as important, continue to learn from each experience, record
it, and pass on your wisdom to the next team. And wish them success.

5. Was there any
aspect of team leadership you predetermined you would be adept at but
found needed improvement, or a total rehaul?

Coming
from a busy trauma center, running a casualty resuscitation was second nature,
but what I needed to do more of is team-building and preventing compassion
fatigue.

6. Any leadership
aspect you had not considered or discounted that you found you had to
learn on the fly?

What
would have been useful is de-escalation techniques during confrontations,
whether as a third party observer or directly involved. Deployed
individuals are stressed, fatigued, and prone to respond poorly to perceived
slights or confrontation. Leaders should stay vigilant of this tendency
in themselves and others and respond with compassion and de-escalate the
situation.

7. When the
teams form initially, do the members automatically register this concise
preformed process or does the process not always work as well as you wished?

In
general, when teams form, they naturally follow the model and do great without
any catastrophes. Viewing the evolution of team formation with this
objectivity would help you see the bigger picture, anticipate likely scenarios,
and to plan ahead. In general, being social animals, people do well as a
team. It is only rarely that a member of the team may be maladjusted
sociopaths who could sabotage your team. These individuals should be
removed from the team early if possible. I see no other solution.

This
aspect of commanding the room goes back to practicing drills and getting used
to running actual resuscitations so that the team members associate the voice
as the Trauma Team Leader. Likely, there will be more than one TTL; we
had several. In this instance, a quick pre-brief that includes the team
member's rolls should also clearly identify who the TTL will be and establish
this hierarchy for a given casualty. During the training, drilling, and
coaching of a TTL candidate, they should be taught and reminded to assume the
"command voice" which is not necessarily loud, but loud enough for
most situations for all to hear and listen. More importantly, it should
be confident, precise, and succinct. Deeper male voices seem to help, but
I have seen many small female surgical residents assume this voice quite
effectively, leading difficult resuscitations with authority.

One
other technique is to "reboot" the room by reviewing the primary
survey and current status of the patient to get everyone on the same wavelength
to focus on the most important tasks at hand.

In
addition, the other team members in the room should be empowered to practice
crowd control - less people in the room equals less extraneous noise.
People talking about other topics besides the casualty or joking around should
cease or be excused from the vicinity of the trauma bay.

9. If a team member
attempts to take control but is clearly wrong, how do you redirect them?

If
the action is not life-threatening, then it can be discussed afterwards during
the debrief and later during peer-review. It may even be a learning point
for all the team members and can be incorporated into didactic training.

If
the wrong action will lead to harm for the patient, it must be stopped and
corrected immediately. The interaction and apologies for hurt egos can be
discussed afterwards during the debrief.

10. Any particular
lesson learned about combat care you did not expect but sticks with you
today?

Having
had a few sudden deaths in patients that appeared fairly stable when they were
physiologically compensating, I still worry particularly about patients who on
the surface seems to be doing unusually well despite severe injuries or
mechanism of injury.

11. Have you arrived
at a treatment facility and just did not have time for orientation and
rehearsals?

Fortunately,
I have not had that experience. Our team had time to work out the kinks
with drills and had time to set up. You would just have to trust that the
training works and the team members you work with are also well trained.
If things are so rapid and chaotic, more communication among team members would
be needed including their identification and role during the
resuscitation. If there are few minutes to spare prior to the arrival of
the casualty, the pre-brief is useful to establish roles, ensure personal
safety, review the basic steps through primary survey, secondary survey, and
disposition plans. Immediately debrief the team if time allows before the
next casualty.

12. Have you missed
something that in looking back was obvious?

Allowing
the team to decompress and hangout together is one major pillar that maintained
a functional team.

13. Did you ever
receive a godsend help when you were praying for it that arrived from a
source you least expected it?

An
excellent CRNA who was able to place an IV on an infant in hemorrhagic shock
when all IO's failed and I could not place a central line.

14. When you
first started, what technique worked best for you in controlling your
anxiety? What about controlling another's anxiety? Or maybe you never had
a situation that did not pose a threat and therefore was not anxiety provoking?

Keeping
physically fit kept me resilient to anxiety, but what exponentially helped that
resilience was meditation. It really works. I would recommend it,
just not the pseudoscience of some types of meditation trends. As for
anxiety in others, developing a strong emotional IQ to detect and ameliorate
the others' anxiety would be my only advice.

15. When you
encounter a patient who has no chance for survival but clearly has their
mental faculties totally intact what does one say to them?

If
he has family and friends, they should be with them without me monopolizing the
little time he has. If there is no one, I would be there to listen to his
requests, keep him comfortable, allay his fears, and not abandon him.

Thank you
so much for your questions. I enjoyed responding to them. Please
let us know if you have further questions.

Tuesday, November 22, 2016

On March 30 1981, 2:27 pm, John Hinckley
Jr shot President Ronald Reagan, White House Press Secretary James Brady,
Secret Service agent Tim McCarthy and Washington D.C. police officer Thomas
Delahanty using his Röhm RG-14 .22 cal blue steel revolver loaded with six
"Devastator" brand cartridges (each with small aluminum and lead
azide explosive charges designed to explode on contact). Hinckley fired six
shots in 1.7 seconds, first hitting Jamey Brady in the head and then officer
Delahanty in the neck. As Special Agent Jerry Parr pushed President Reagan into
the limousine, a fourth shot hit Secret Service agent Tim McCarthy in the
abdomen. The sixth bullet ricocheted off the armored side of the limousine and
hit the president.

It was initially assumed that The
President was uninjured. Thinking he was uninjured, they initially planned to
take the President to the White House. Until he coughed up blood, President
Reagan assumed the pain in his left chest was due to rib fractures from being
pushed into the limousine. Special Agent Parr thought otherwise and directed
the motorcade to George Washington University Hospital. Upon arrival the
President walked into the Emergency Department unassisted but immediately
collapsed. At the insistence of The Physician to the President, Daniel Ruge,
the ED team was instructed to treat the President as any other trauma victim.
The President was in shock and the Trauma team quickly discovered a bullet
entrance wound in his left axilla. Within 30 minutes, he was stabilized and
transported to the Operating Room where, with the assistance of Joseph M.
Giordano, Chief Thoracic Surgery Benjamin L. Aaron, performed a thoracotomy. Wikipedia, NY TImes

An interview a few weeks later
revealed the anxiety control methods both surgeons utilized when they realized
they were operating on the President:

Giordano: ''I looked at
him and I could feel myself getting tense, which has happened to me
occasionally when I do surgery. When that happens, I talk myself through it. I
thought, 'O.K., calm yourself. You want this to go well. Concentrate, and do
everything the way you always do it, if you expect to get good results.' But I
could not divorce myself from the fact that he was the President and his wound
could have been lethal.''

Aaron: “He assessed
the seriousness of the President's wounds, and said he too would have had ‘heightened
anxiety’ if he had not judged that Mr. Reagan's bleeding could be controlled.
Although Dr. Aaron described himself as someone who ''doesn't get anxious about
things,'' he acknowledged that he was ''on edge at times.'' ''When I couldn't
feel that bullet, and I knew it should be there, I thought it might have
embolized through the pulmonary veins, into the heart and gone someplace.'' …The
bullet, it turned out, was flat. ''I just couldn't feel it in that spongy lung
tissue,'' Dr. Aaron said. ''The X-ray settled me down because I realized that
when I was feeling for the bullet it wasn't trapped in one place. It had room
to move, and it just squirted away from my fingertips.” ''Then it was just a
matter of hanging in there until I could find the blooming thing by passing a
catheter along the bullet track. It took about five minutes of very
concentrated tactile discrimination until I suddenly pinned it down and got it
out.''

INTERVIEW WITH BEN AARON, MD:

After Jon White revealed the heroic
aspects of the team saving the Presidents life I had questions of Dr. Aaron:

1. What leadership or
crisis management experience /techniques did you discover worked well for you?

5. What lessons did
you rehash with the residents and /or hospital staff in post scenario
debriefings?

Dr. Aaron was kind to discuss this
with me:

“Bear in mind that all this took
place 35 years ago and that it is coming from an 83 year old brain. Also,
at the time, things were moving at a fast pace during which time there was not
much time for reflection or organization, or to put it another way, much of the
time we were "winging it" in dealing with the complexities imposed by
the unique nature of the event. “

1. Leadership or crisis management experience/techniques applied?

The care in the ER was
flawless as regards urgent processing, mobilization of staff and systematic
application of appropriate care. This was not an accident, but came about
because of aggressive and thorough preparation and training of the ER staff and
residents. In order to take care of the President, James Brady and Tim
McCarthy (SS), the area had to be cleared of patients, the ensuing crowd
screened and managed, and assignments quickly defined. No one consulted
any manuals on procedures on techniques. The key was preparation and
training, professionally applied.

I recall
insisting, from the get-go, that everyone on my team regard the President first
and foremost as a patient in trouble and to put aside any consideration of who
he was or what might be swirling around beyond our perimeter of care.
This kept us focused on the task at hand and help quell nervousness. You
might call this the principle of putting first things first. I did not
note it at the time, but have been told since that as the team leader, my calm
demeanor, efficiency, decisiveness and apparent lack of nervousness did much to
hold things together as this event moved along. (Jon White, MD noted that this
was indeed the case- Dr. Aaron maintained a calm demeanor with no yelling and
no screaming, which allowed flawless communication and the ability to
resuscitate the President and rapidly transport him to the OR).

2. Consideration of changes or alterations.

One can be
persuaded in such a situation that having additional professional experience at
the table could be helpful and perhaps diffuse responsibility should things go
wrong. I had many offers of help from fellow surgeons, but quickly put
this aside in favor of a three-person team composed of me, my chief Thoracic
resident and a surgical intern (just as it would be if the patient came in off
the street). This seemed to me to be the simplest route to good decision
making during the operation. This might be termed good management versus
too many "cooks" calling the shots.

Because of the
remote possibility that the bullet might have transited the dome of the left
diaphragm, the ER General Surgeons strongly supported an abdominal paracentesis
before opening the chest to rule out injury to the spleen, etc. I had seen no
evidence of this and had reservations about taking the time to do the procedure
(20 minutes or so), but as the President's condition was stable at the time, I
agreed to move ahead on this even though had I found a hole in the diaphragm, I
could easily have dealt with the problem through the chest. This gets
down to using clinical judgment (was it safe to take the additional time) to
forestall a fuss with the General Surgery group.

Putting the
President, post-op, on the ICU was a management mistake, as his presence along
with all of his SS entourage and visiting staff rendered the ICU
unworkable. We quickly evacuated a wing of the hospital, tailored it to
all the requisites and had the patient moved in 6 hours. My plan for
post-op care was drastically and suddenly altered but I and my team quickly
adapted to the new circumstances and moved on. Being flexible, prepared for
contingencies, and able to move in different directions effectively is
essential to completing the mission.

3. How ready were we?

Occasionally one
hears that University medicine is "sterile", impersonal, isolates a
patient from compassionate care and has poor inter-staff communication.
Some of this may be true, but what University Medical centers do provide is
well credentialed and experienced staff and first rate facilities. We
were prepared for this challenge at every level of staff, management and resource
availability and because of this, the event came off without a significant
hitch. It was a team effort in every regard from beginning to end and a
wonderful thing to be a part of.

4. What plans or preparations proved false?

We were not
prepared for the security requirements by the SS. There was a SWAT team
on the roof at all times during the eleven days he was present. When he
needed good quality x-rays (there was a portable machine in his suite), the
halls had to be cleared and explosive sniffing dogs preceded his visit to the x-ray
floor. His food supply was carefully guarded. Bullet proof glass was
installed in his room (despite the fact that he was on the 3rd floor of an
interior court with a window free wall opposite). ALL entrants to the 3rd
floor had to undergo a SS check, each and every time they entered.
Medical folk, especially doctors, are not particularly patient people by
nature, so with great restraint, and resolve, we managed to work it through to
a successful conclusion. The lesson here is to practice situational
awareness and be willing to accept imposed restraints, always keeping the
mission as our first goal.

5. Post event debriefing.

Post mortems are
standard issue for any medical event. We had many discussions after the
fact, but almost all centered about things like conduct with the intrusive
press (residents and especially interns, are full of false info and quite
willing to share it). To relive and relieve tensions. we produced a high
quality 30-minute documentary utilizing all the primary participants (doctors
and nurses, etc) plus actors as the presidential party. This process
brought out into the open the vital parts played by each participant and
highlighted the importance of the synthesis of each performance in attaining a
good outcome. On almost every count, we were satisfied with how our
medical center responded to each and every challenge and this was echoed by the
AMA in their commendation of our efforts.

I hope that this insight into how
our medical center and all it's integrated parts dealt with a most unusual and
unexpected event will help you develop a useful syntax for your book. If
you have additional questions, fire them my way and I will field them as best
as I can.

Sincere regards, Ben Aaron, MD

Special
thanks to Dr. Jon White, Chief Surgery VAMC Washington DC for filling in the
gaps.